School sports & Youth injury:

The promise..and the peril.

ACSP 2016
James MacDonald, MD, MPH
Associate Professor of Clinical Pediatrics
Ohio State University College of Medicine
Team Physician Ohio Dominican University, Bexley High School
@sportingjim, @cjsmonline
Cjsmblog.com
....

Disclosures
MomsTeam Institute, 501(c)(3), Board of Directors
http://momsteam.com/

Wolters Kluwer
Clinical Journal of Sport Medicine (CJSM), Associate Editor
Up To Date, Author

Disclaimer
I speak English..
but am an American

College = Uni
Resident = Registrar
Pants = Trousers
High School = College?
Football = ?????

Nationwide Childrens Hospital

Division of Sports Medicine

Columbus, Ohio

Pedi sports only (7 docs)

Academic appts:
Ohio State University
Patient mean age :14.2 ( 7 19)
15,500+ patient visits/2015
NCH Division of Sports Med
Roughly 50/50
overuse/acute
1 University, 15 High Schools.
Other.

Pediatric SRCs at NCH

2015 Concussion Total
Sports Medicine
Jan-Jun

Jul-Dec

Total

New Patients

421

689

1110

Follow Up

810

1054

1864

1231

1743

2974

Grand Total

What well cover (or)

If it bleeds, it leads
USA Youth Sports Culture

How sport may fail our

Epidemiology
kids
Pressures
Injury prevention in
Overuse injuries
youth sports
Early Sport Specialization Public health issues
Acute injuries
Why sports matter for
Contact sports
Concussion

kids
Free play and Exercise
is Medicine

The Pedi/Adolescent athlete: 2015

60 million children (6 18) play sports
30% specialize in one sport

27 million play team sports

General trends

Early sport specialization

Multiple teams (e.g. travel teams)
Year-round training
Costs are climbing

By 2020, 27% of U.S. public high

schools won't have any
interscholastic sports.
....
CJSM 2014 DiFiori et al.
Sport Health 2016 Myer et al.

My how its changed

The Race To Nowhere in
Youth Sports

John O'Sullivan TED Speaker

You cant start soon enough...

How crazy are youth sports?

Just ask university students

NCAA 2016 Data

Under Pressure
Tommy John Surgery (UCL
Reconstruction) increase
193% in UCL surgeries over
10 years.
Age = 21.6 +/- 8.89
Trend for increased frequency
ages (17 18) & (19 20)
(P < 0.001)

AJSM 2016; published on line first

Epidemiology overuse injuries

Overall estimates of overuse
injuries versus acute injuries
range (45.9% - 54%).
Thought to be underestimate
68% higher overuse injury rate
for private vs. public insurance
High rates (different studies)

Gymnastics
Runners
Swimmers
Baseball pitchers

Jayanthi 2015

Definition overuse injury

Occur due to repetitive submaximal loading of
MSK system
Rest not adequate for structural adaptation to occur

Injury may involve muscle-tendon unit, bone,

bursa, NV structures, physis/apohysis
Unique to young athletes include
Apophyseal injuries
Physeal stress

Examples
OSD, proximal humeral epiphysiolysis, spondylolysis,
OCD knee/talus

Sports-specialized intensive training

& the risk of injuries
OTS (Age = 7 18)
Sports injured/non
injured
Independent risk factors
for overuse injuries
Hrs OTS/week > age in
years [OR 2.07 (1.40
3.05) P < 0.001]
Ratio of OTS > 2:1 [OR 1.87
(1.26 2.76) P < 0.01]

Jayanthi et al. 2015; AJSM

EM risk factors for overuse

i)Can you pick a main sport? ii) Did you quit other sports to focus on a main
sport? iii) Do you train > 8 months in a year?

Jayanthi et al; AJSM 2015

Risk Factors for Overuse Injuries

Overuse Injuries and Burnout in Yout

h Sports: A Position Statement from
the American Medical Society for Sp
orts Medicine

Sport Specialization

DiFiori, John P.; Benjamin, Holly J.;

Brenner, Joel; Gregory, Andrew;
Jayanthi, Neeru; Landry, Greg L.; Luke,
Anthony
Clinical Journal of Sport Medicine.
24(1):3-20, January 2014.
doi: 10.1097/JSM.0000000000000060
TABLE 2 Categorization of Risk
Factors for Overuse Injury

Copyright 2015 Clinical Journal of Sport Medicine. Published by Lippincott Williams & Wilkins.

16

Early sport specialization

what for?
UCLA athlete survey
(N = 296)
(Age = 19) male/female

88% participated in 2 3
sports as youth
70% did not specialize in
one sport < 12
40% of the NCAA
athletes had a parent at
collegiate or professional
level
Abstract presented 2013 AMSSM. DiFiori
and
CJSM 2014 Quitquit, DiFiori

NCAA 2016 Data

Even worse for the women?

Scholarships:
the Narrow Gate

Alternatives to sport
specialization

....

Concussions -- epidemiology
3.8 million pediatric SRCs /yr1
50% of HS football players
dont report/season2
Injuries (total) kids (7 13)6
Almost 9% of HS sports
Football 1.5/10000 AEs
injuries are concussions4
Baseball 1.7/10000 AEs
Rates in HS sports3:
Football 6.4/10000 AEs
Boys Ice Hockey 5.4/10000
AEs
Boys LAX 4.0/10000 AEs
Girls LAX 3.5/10000 AEs
Girls Soccer 3.4/10000 AEs
Boys Soccer 1.9/10000 AEs

Boys Soccer 1.7/10000 AEs

AJSM 2012
CJSM 2004
3
AJSM 2012
4
Pediatrics 2010
5
AJSM
6
Pediatrics 2015
1

Im not a doctor but I play one in the

movies

....

....

Youth football:
the scope of the sport

....

CJSM 2013

CTEpractice & research gaps

....

Castellani, Laboratory Investiation

2015

Repetitive Head Impacts:

cause for concern?
Cumulative Head Impacts
(Subconcussive blows)?
HS/College 1000 head impacts/season
Youth (age 6) 100 head impacts/season
Can generate impacts equivalent to collegiate
athletes

Animal Models
Changes in White matter
Concussion Dose/Response Model

....

Tackling in football
Tackling is most common
activity at time of injury
Majority of concussions
result from tackling/being
tackled
Incidence of concussion
lower in practice than
games
But there are many more
practices
In youth (not HS/College)
measured head impact
forces are higher in practices

Recommendations
Decreasing # of contact
practices decreases overall
number of head impacts
over the course of a season
Emphasis on proper
tackling
technique/enforcing rules
?Delay onset of tackling
until a certain age?
Importance of having ATCs
present at schools

Pediatrics 2015
AAP Policy Paper on Tackling

Helmetless tackling???!!

NCAA D1 Athletes
25 cases/25 controls
Impact sensors
Intervention:
5 min 2x week
preseason, 1x week in
season, helmetless
tackling drills

Outcome: 28% less

head impacts
JATA 2015

Rugby, football.football, rugby

NFL

Rugby League

Contact sports: is age all that matters?

Youth Ice Hockey

Outcome measures:
Symptom duration post
concussion > 28 d

Independent variables
Age, gender, weight
Pubertal category scale (PCS)

Notably early PCS

strongest predictor of
prolonged symptoms
among boys (N = 101)
[OR = 4.29 (1.24, 14.85)]
(P < 0.21)

Kriz, Journal of Pediatrics 2016

Contact Sports: Is
Concussion all that
matters?

....
Doug Casa, Korey Stringer Institute
AJSM 2013

[N = 243 (1990 2010)]

First, Lets Kill All the Lawyers the Bard

Crystal Dixon, et al v. Pop Warner Little
Scholars, Inc.
.. about the failure to coach the injured
plaintiff in proper tackling technique and
whether there was a conscious disregard
for his safety based on the evidence
presented.

Lawmakers in MD
Bill to suspend coaches who return players
suspected of concussions on to playing field
....

Social Media & Hornets

Nests
Gun safety
#OscarsSoWhite

Concussions/CTE
Vaccines
Paleo Diet
Bike Helmets
Cross-Fit
Open Access

The concussion crisis:

Science
Advocac
y

Media

Business

Crisi
s

Litigatio
n

Risk
Percepti
on

....

Scientific Evidence Disseminated = Balance

You dont need a weatherman to

know which way the wind blows
Survey by the Sports and Fitness Industry
Association and the Physical Activity Council:
2012 participation in organized football by players
aged 6 - 14 was 4.9 percent below that in 2008.

National Federation of State High School Assns:

Participation in high school football was down 2.3
percent in 2012-2013 compared to the
2008-2009 season.

....

WSJ 2013

Weve been talking about this a long

time

Football has become soft like our

country has become soft

Relative Risk
2694 children/teens died from guns 20101
638 children < 12 died in MVAs 20132
17 Football Season Fatalities, 2015 3
Indirect: 10 (Mean = 7/last decade)
SCD = 6
EHS = 3
Sickling crisis = 1

Direct: 7 (Mean = 3/last decade)

4 head
2 spinal cord
1 organ
....
1
3

Children's Defense Fund, 2 CDC,

Korey Stringer Institute

Pedi Injury Prevention

Preseason training
Resistance training

Gradual increase in
volume/intensity
Rule of 10%/week

Hours/week in OTS < Age

Stretching?
Considerable debate
(probably not)

Pre-participation NM
training (e.g. FIFA11+)
Pre-season conditioning
Neck strength
concussion prevention

Pediatric Resistance Training

reduces kids sports injuries

Heidt et al, AJSM 2000

Hewett et al, AJSM 1999
Mandelbaum et al, AJSM 2005
Cahill et al, AJSM 1978
Hejna et al., NCSCA J 1982
Olsen et al., BJSM 2005
Wedderkopp et al, Scand J Med Sci Sports, 2003

And its safe!!!!

Faigenbaum et al. BJSM 2015

Pediatric Resistance Training

Improving performance

Systematic Review
Youth (6 18)
(N = 43) included
Effects
moderate
Muscle strength
Vertical jump

small
Linear sprint speed
Agility
Sport-specific performance

BJSM 2016

Ideal training regimen

Period > 23 weeks

5 sets/exercise
6 8 repetitions/set
Intensity 80 89% (RM)
3 4 mins rest/set

muscle strength
Sessions/week*
Begin with 2, move to 4

*BJSM 2015

Athletic Trainers (ATCs)

Licensed medical professional in USA

70% USA HS has some and 37%
have full time1
Linked to injury reduction
2012 AAP National Conference2
HS girls basketball and soccer
Schools without ATC had injury rates
1.73 x higher in soccer
1.22 x higher in basketball

Recurrent injury rates

5.7 x higher in soccer
2.97 x higher in basketball

Concussion rates
8.05 x higher in soccer
4.5 x higher in basketball
J Athl Train 2015
AAP Conference 2012

1
2

http://www.pediacast.org/the-sports
-medicine-team-pediacast-332
/

Team sports no guarantee of exercise

....
Archives of Pediatrics and Adolescent
Medicine 2010

Archives of Pediatrics and Adolescent Medicine

2010

....

Unstructured Free Play

Child-driven play

Learn to work collaboratively

Learn at own pace
Learn creativity
Practice decision-making
Practice arbitration
Avoid burnout, stress

60 mins MVPA more likely

Exercise is Medicine: for kids brains (or)

Everything in moderation
Large (N = 3235) birth
cohort study, Brazil
Independent variable =
Self-reported physical
activity 11, 15, 18 y*

Dependent variable =
Cognitive performance
(Weschler Adult
Intelligence Scale) 18 y

Age 18 Highest MVPA

tertile did WORSE than
lowest!
MSSE 2015

*Objective measurement at 18

Lets Quantify the Benefits

....

Which
is the pediatric
publicpads
health
Sacrificing
football
crisis of our times?

for...iPads

Keeping it fun!

Increase amount of unstructured

free play (FP)
Time in FP 2x as much as organized
sports (OS).

Do not spend more hours per week

playing sports than your age
(e.g. 10 year old should play <
10 hrs OTS)

Do not specialize in one sport before

late adolescence*
Do not play sports competitively
year-round.
Take at least one day off per week
from sports training.

*very few exceptions to this rule

Sportstheyre mudlicious
Overuse injuries
Very common
Entirely preventable

Acute injuries
Concussions & more

Youth sports culture

Let kids be kids

Alternatives to sports
The benefits of free play!

Lets keep kids active & safe

Thank you!
One of the few moments
of happiness a man knows
in Australia is that moment
of meeting the eyes of
another man over the tops
of two beer glasses.
--Bruce Chatwin, The Songlines

@sportingjim @cjsmonline

References

Hyman, M. Until it Hurts (2010) & The Most Expensive Game in Town (2012). Beacon
Press.
DiFiori J, et al. Overuse Injuries and Burnout in Youth Sports: A Position Statement from
the American Medical Society for Sports Medicine. Clinical Journal of Sport Medicine
2014; 24: 3 20.
Jayanthi NA, LaBella CR, et al. Sports-specialized Intensive Training and the Risk of
Injury in Young Athletes: A Clinical Case-control study. AJSM 2015; published on-line.
Myer GD, Jayanthi N, DiFiori JP, et al. Sports Specialization, Part II: Alternative Solutions
to Early Sport Specialization in Youth Athletes. Sports Health. 2016; published on line
first: DOI: 10.1177/1941738115614811.
Meehan WP, Landry GL. Tackling in Youth Football; AAP Council on Sports Medicine &
Fitness Policy Statement. Pediatrics. 2015; 136: e1419 e1430.
Lesinski M, Prieske O, Granacher U. Effects and Dose-Response Relationships of
Resistance Training on Physical Performance in Youth Athletes: a Systematic Review
and Meta-analysis. Br J Sports Med. 2016; published on line first: DOI: 10.1136/bjsports2015-095497.
Faigenbaum AD, Lloyd RS, MacDonald J, Myer GD. Citius, Altius, Fortius: Beneficial
Effects of Resistance Training for Young Athletes. Br J Sports Med. 2015; published on
line first: DOI: 10.1136/bjsports-2015-094621
....
Kriz PK, Stein C, Kent J, et al. Physical Maturity and Concussion Symptom Duration
among Adolescent Ice Hockey Players. Journal of Pediatrics. 2016; published on line
first: DOI: 10.1016/j.jpeds.2015.12.006